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request assignment of a level of need (LON) when necessary (Purpose Code 4);

request an LOC and LON for a lapsed ID/RC assessment (Purpose Code E for ICF/IID only); and

demonstrate compliance with federal utilization review requirements.

CLASS and DBMD

request a level of care (LOC) assignment (Purpose Code 2);

comply with continued-stay review (Purpose Code 3);

demonstrate compliance with federal utilization review requirements.

Note: When a Related Condition is a primary diagnosis:

Use Form 8662, Related Conditions Eligibility Screening Instrument, to verify a diagnosis of a related condition. For CLASS and DBMD, complete this form and submit with Form 8578. For ICF/IID, HCS, and TxHmL, refer to Determination of Intellectual Disability (DID) Best Practice Guidelines.

The related condition must be listed on the HHS Approved Diagnostic Codes for Persons with Related Conditions List (See the list at ICD-10).

Procedure

When to Prepare

Complete Form 8578 using information collected from the applicant or provided by an interested party on behalf of the applicant when an LOC and LON assignment is requested. Once a person is enrolled in a program, this form is completed for every LOC or LON action.

Transmittal

For HCS and TxHmL, the LIDDA or provider enters Form 8578 information into Client Assignment and REgistration (CARE).

LON Increase Packet Transmittal

For HCS, TxHmL, and ICF/IID, the LIDDA or provider submits a packet when requesting an LON increase to IDD Waivers/Community Services/Utilization Review for review. Refer to the LON Resources link for instructions.

Form Retention

Retain copies of all forms in accordance with Texas Administrative Code Title 40 Part 1, Chapter 49, Subchapter C, Record Retention and Disposition, §49.307. The ICF/IID provider or LIDDA must keep the records of people under 18 years of age for three years past their 18th birthday even if the retention period exceeds six years.

Physician's Signature (Complete for ICF/IID Only)

For a person requesting admission into an ICF/IID, Items 19 and 48-55 must be completed, and a physician must sign the paper copy (Item 52) attesting to the information documented in Items 19 and 48 through 51. The physician's name must be printed in full in Item 53.

For a following Form 8578, if the physician has delegated the completion of Items 19 and 48-55 to an advance practice nurse (APN) or a physician assistant (PA), the APN or PA must sign the paper copy (Item 52 attesting to the information documented in Items 19 and 48-51). The APN's or PA's full name must be printed in Item 53. The physician's license number must be noted in Item 55 and the APN's or PA's license number noted in Item 72.

Diagnosis

A primary diagnosis is the condition chiefly responsible for the request for programmatic services.

20. Code

Code of primary diagnosis listed in the International Classification of Diseases (ICD).Note: This code must match the primary diagnosis entered in Item 19 on the original (hard) copy.

21. Version Code

Version of the ICD in use by HHSC at the time of the diagnosis for the individual's primary diagnosis.

22. Onset

Month and year of the onset of the individual’s primary diagnosis.

23. Medical Diagnosis/DBMD Second Condition

Any current medical diagnoses that the person may have as determined by a licensed physician. Used to indicate factors that have a direct bearing on the required treatment or care or DBMD second condition.

24. Code

Code from the ICD indicating the individual's current medical diagnosis or DBMD second condition.

25. Version Code

Version of the ICD in use by HHSC at the time of the diagnosis for the person’s medical diagnosis or DBMD second condition.

26. Psychiatric Diagnosis/Additional Diagnosis(es)

Diagnosis if the person has any current mental disorder, behavioral health disorder(s) or DBMD additional condition as diagnosed by a licensed physician or an authorized provider in accordance with the Diagnosis and Statistical Manual of Mental Disorders (DSM) or ICD.

27. Code

Code from the DSM or ICD for the person’s psychiatric diagnosis or DBMD additional condition.

28. Version Code

Version of the DSM or ICD used for the person’s psychiatric diagnosis or DBMD additional condition.

Cognitive/Adaptive Functioning

Item Name

Contents

29. IQ

Current IQ score. Must use Determination of Intellectual Disability Best Practice Guidelines (DID BPG). (Only applicable to HCS, TxHmL, and ICF/IID)

Assessment Date To be used by CLASS and DBMD. Date that adaptive behavior level was assessed using one of the approved instruments.

71. Level of Consciousness

Level of Consciousness – The state of awareness, varying from alert wakefulness to a complete lack of responsiveness. This item must be number 1, 2 or 3 for the individual to be eligible for CLASS or DBMD.
1 = Alert – responds quickly to verbal stimuli or/and the environment
2 = Lethargic – easily aroused, but drowsy; may follow two-part commands
3 = Stupor – very hard to arouse; may require vigorous stimuli; may follow simple commands
4 = Comatose – unable to arouse; does not respond to vigorous stimuli; unable to follow commands

74. Score Identified by ABL Instrument

To be used by CLASS and DBMD. The provider notes the assessment score identified by the selected ABL instrument in the applicable format.

75. Functional Assessment

To be used by CLASS and DBMD. The provider notes the total number of Yes responses in Section 4 A.-F. of Form 8662, Related Conditions Eligibility Screening Instrument.

ICAP Data (not required for DBMD and CLASS)

Item Name

Contents

31. Broad Independence

Domain score calculated from the Inventory for Client and Agency Planning (ICAP) assessment.

32. General Maladaptive

Score with + or −, as applicable (CARE system only accepts "−" from key above "p" on computer keyboard).

33. ICAP Service Level

Person’s actual service level obtained from the ICAP assessment.

Behavioral Status (ICF/IID, HCS and TxHmL only)

Item Name

Contents

34. Behavior Program

Y (Yes) or N (No) to indicate if a behavior program is in place for the person.Note: If a value of N is entered, Items 35-38 must have a value of 0.

35. Self-injurious Behavior

(Behavior examples include self-inflicted tissue damage, including that related to property destruction, pica and excessive food consumption for individuals with Prader-Willi syndrome.)
Code to indicate Level of Caregiver Preventive Intervention:
0 = Not applicable or not on behavior program
1 = Requires additional staff supervision to prevent dangerous behavior (this code indicates a Behavior increase request)
2 = Requires constant one-on-one supervision during waking hours to prevent extremely dangerous behavior that could be life threatening to the individual or to others. (this code indicates a request for LON 9)Note: If a value of 1 or 2 is entered, then a Behavior Program must be in place for the individual (Item 34=Y).

36. Serious Disruptive Behavior

(Behavior examples include threatening strangers, running into traffic and public disrobing.)
Code to indicate Level of Caregiver Preventive Intervention:
0 = Not applicable or not on behavior program
1 = Requires additional staff supervision to prevent dangerous behavior
2 = Requires constant one-on-one supervision during waking hours to prevent extremely dangerous behavior that could be life threatening to the individual or to others.Note: If a value of 1 or 2 is entered, then a Behavior Program must be in place for the individual (Item 34=Y).

37. Aggressive Behavior

(Behavior examples include physical attacks against others.)
Code to indicate Level of Caregiver Preventive Intervention:
0 = Not applicable or not on behavior program
1 = Requires additional staff supervision to prevent dangerous behavior
2 = Requires constant one-on-one supervision during waking hours to prevent extremely dangerous behavior that could be life threatening to the person or to others.Note: If a value of 1 or 2 is entered, then a Behavior Program must be in place for the person (Item 34=Y).

38. Sexually Aggressive Behavior

(Behavior examples include sexual assault, pedophilia and public masturbation.)
Code to indicate Level of Caregiver Preventive Intervention:
0 = Not applicable or not on behavior program
1 = Requires additional staff supervision to prevent dangerous behavior
2 = Requires constant one-on-one supervision during waking hours to prevent extremely dangerous behavior that could be life threatening to the person or to others.Note: If a value of 1 or 2 is entered, then a Behavior Program must be in place for the individual (Item 34=Y).

Code to indicate the frequency of nursing services for the individual
0 = Individual does not have these services included in the IPP, ISP or IPC
1 = 15 minutes or less per week (0-13 hours per year)
2 = 16-30 minutes per week (14-26 hours per year)
3 = 31-60 minutes per week (27-52 hours per year)
4 = 61-149 minutes per week (53-130 hours per year)
5 = 150-180 minutes per week (131-156 hours per year)
6 = 181 or more minutes per week (157+ hours per year)

Day Services

Field Name

Contents

41. Service

Code to indicate if the person participates in day services (group settings that are not individualized, including sheltered workshops and enclaves).
0 = Person does not participate
1 = Person does participate

42. Frequency Code

Code to indicate the frequency of the individual's participation in day services.
0 = Person does not participate in day services
1 = up to 5 hours per week
2 = 6-10 hours per week
3 = 11-15 hours per week
4 = 16-20 hours per week
5 = 21-25 hours per week
6 = 26 or more hours per week

Functional Assessment

Item Name

Contents

47. Ambulation

Code to indicate the person’s ambulation.
1 = Walks independently; walks with no supervision or physical hands-on assistance. May require mechanical devices (such as cane, crutch or walker), but not a wheelchair.
2 = Walks with intermittent supervision or physical hands-on assistance for difficult maneuvers (such as for stairs, ramps). May or may not require the use of mechanical devices (such as cane, crutch or walker), but not a wheelchair.
3 = Walking requires constant supervision, physical hands-on assistance (with or without mechanical devices, but not a wheelchair), or both.
4 = Wheelchair is the most appropriate method of ambulation.

Physician's Evaluation and Recommendation (ICF/IID Only.)

Item Name

Contents

48. Does medical regimen of the individual need to be under the supervision of an M.D./D.O.?

Check Yes or No to indicate if the person's medical regimen needs to be under the supervision of an M.D. or D.O.Note: Yes must be indicated for the person to be eligible for ICF/IID program.

49. Will the health status of the individual prevent participation in the active treatment of the ICF/IID program?

Check Yes or No to indicate if the person’s health status prevents participation in the active treatment of the ICF/IID program.Note: No must be indicated for the person to be eligible for ICF/IID program.

50. To your knowledge, does the individual have a condition of intellectual disability (previously referred to as "mental retardation") and/or a related condition?

Check Yes or No to indicate if the person has a condition of intellectual disability or a related condition.Note: Yes must be indicated for the person to be eligible for ICF/IID program.

51. Do you certify that this individual requires ICF/IID or ICF/IID-RC care?

Check Yes or No to indicate if you certify that this person requires ICF/IID care.Note: Yes must be indicated for the person to be eligible for ICF/IID program.

52. Signature – I attest to Item 19 and Items 48-51 only.

Signature of the M.D./D.O./Advance Practice Nurse/Physician Assistant.
For admission to ICF/IID, signature of the M.D./D.O. is required. Signature by designee is allowed for subsequent ID/RC Assessments.

Date of the signature of the RN/LVN/QIDP/ Case Manager/LIDDA Service Coordinator/HCS Provider Representative who signed the form.

63. Effective Date

Effective date of the LOC determination/LON assignment.

64. Expiration Date

Expiration date of the LOC determination/LON assignment.

65. Name of Reviewer

Name of HHSC staff person reviewing the assessment and assigning the LOC/LON.

66. Date Reviewed

Date the assessment was reviewed.

67. Name of Physician

Name of the HHSC physician or designated staff person who reviews the assessment when LOC has been denied (if applicable).

ABL Determination for CLASS and DBMD Programs (HCS/TxHmL and ICF/IID only) must refer to the DID Best Practice Guidelines

ICAP Conversion

Service Level

Adaptive Behavior Level

7,8,9

I

4,5,6

II

2,3

III

1

IV

SIB-R Conversion

RMU Range

Adaptive Behavior Level

82/90 – 100/90

I

34/90 – 81/90

II

5/90 – 33/90

III

0/90 – 4/90

IV

Calculating Level of Need (LON) (HCS/TxHmL and ICF/IID only)

LON Description

ICAP Service Level

Service Score Range

Other

1 Intermittent

7, 8 or 9

>+ 70

5 Limited

4, 5 or 6

40 – 69

8 Extensive

2 or 3

20 – 39

6 Pervasive

1

1 – 19

9 Pervasive +

Any

Any

Must have a value of 2 in at least one of the following items:
35. Self-injurious Behavior
36. Serious Disruptive Behavior
37. Aggressive Behavior
38. Sexually Aggressive Behavior

Behavior Increase (ICF/IID, HCS and TxHmL only):

If at least one of the behavior Items 35 through 38 is a value of one, then a behavior increase is indicated. If the level of need has a value of 1, 5 or 8, then the requested LON will be increased one level when the ID/RC is electronically transmitted to HHSC. Submit documentation justifying the behavior increase must to HHSC within seven calendar days of the electronic transmission of the ID/RC.

Medical Increase (ICF/IID and HCS only):

If Item 40, Nursing: Frequency Code, has a value of 6 indicating that 181 or more minutes per week of nursing services are provided and Item 39, Nursing: Service Provider, has a value of 15 or 16 (15=Registered Nurse, 16=Licensed Vocational Nurse), then a medical increase is indicated. If the level of need has a value of 1, 5 or 8, then the level of need will be increased one level when the ID/RC is electronically transmitted to HHSC. Submit documentation justifying the medical increase to HHSC within seven calendar days of the electronic transmission of the ID/RC.

LON 9 (ICF/IID, HCS and TxHmL only):

If at least one of the behavior Items 35 through 38 is a value of two, then a LON 9 is indicated, and the requested LON will be increased to a LON 9 when the ID/RC is electronically transmitted to HHSC. Submit documentation justifying an initial LON 9 request to HHSC within seven calendar days of the electronic transmission of the ID/RC.

Other

A LON 6-Pervasive will never be increased to a LON 9-Pervasive + when requesting a behavior or medical increase.

In ICF/IID, a person’s LON can only be increased one time. For example, if an individual's ID/RC satisfies both the behavior criteria for an increase and the nursing criteria for an increase, then the LON is only increased one level.

Cost caps for people enrolled in HCS are based on their LON. If the information on the ID/RC indicates a person receives 181 or more minutes per week of nursing services and these services are provided by a registered nurse (RN) or a licensed vocational nurse (LVN), then that person’s cost cap will be increased to the LON 6 cost cap if the current LON has a value of 8.